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and Disorders: International Journal

Case Report Open Access abuse as a sleep : case reports

Abstract Volume 4 Issue 2 - 2020 Background: Pregabalin is well known as an , and antiepileptic Basavaraja Papanna,1 Carlo Lazzari,2 Kapil medication. It was alarming for mental health service when it started being used as addictive 1 1 agent by patients for its properties. Kulkarni, Sivasankar Perumal 1Essex Partnership University NHS Foundation Trust, UK Methods: We report two cases from Community Mental Health Team who started abusing 2South West Yorkshire University NHS Trust, UK their prescribed Pregabalin. They were closely observed in community and on inpatient unit for their pattern and extent of abuse and dependence criteria. Correspondence: Basavaraja Papanna, Essex Partnership University NHS Foundation Trust, UK, Email Results: Both the patients developed dependence syndrome indicated by tolerance, craving and presented with withdrawal symptoms on stopping Pregabalin. They needed replacement Received: June 22, 2020 | Published: August 26, 2020 medication to manage withdrawal symptoms. Conclusion: Pregabalin has strong addictive potential and mostly abused by people for its hypnotic or sleep-inducing properties. The development of dependence and nature of withdrawal symptoms vary from person to person; however, with long half-life have good potential to manage Pregabalin withdrawal symptoms. Keywords: pregabalin abuse, pregabalin as hypnotic, pregabalin controlled medication, sleep, , ,

Introduction the .14,15 In line with this, The UK government is to reclassify the Pregabalin as a class C controlled Pregabalin is widely used in psychiatric practice to treat people substance, after experts issued safety warnings following an increase with anxiety problems and neuropathic . It also has role as in deaths linked to its use.16 We present here the two cases of Pregabalin 1 adjunctive therapy for focal or generalised disorder. misuse identified in the local community mental health team; we have Pregabalin is a which is derivative of GABA amino highlighted a few related concerns of abuse, including intake of large 2 butyric acid. It was developed as a successor to gabapentin. In United dosages and use in sleep disorder. Kingdom, prescription of gabapentin and pregabalin has increased by 150% and 350%, respectively in the last 5 years. In addition to Case reports licensed use in , both have become a tempting option for other refractory pain syndromes with or without a clear organic Case 1 3 substrate. Pregabalin has also been reported effective in improving Miss A is a 26-year-old lady known to local mental health services sleep quality in patients who suffer from a generalized anxiety with a diagnosis of Emotionally Unstable Personality Disorder, 4–6 disorder, , , or . Multiple case reports Depression and Anxiety. She is also known to have history of and data have shown that Pregabalin is now misuse and occasional abuse. Due to the nature of illness widely known to induce addictive behaviours. There has been a recent particularly personality issues she has had impulsive attempts of self- increase in deaths related to Pregabalin use in the United Kingdom. harm and by overdose of medication, ligature, and cutting her This is due to Pregabalin abuse by the service users along with other wrists. There were several admissions to the psychiatric units both 7–9 substances like , alcohol, to potentiate their effects. The voluntarily and following detention under Mental Health Act.17 She mechanism of addictive potential can be explained by the fact that was on regular : 200mg OD, 200mg therapeutic doses of are dose dependently associated Nocte and Pregabalin 200mg BD along with 1mg up to with a modest increase of the extracellular GABA-concentration BD as PRN medication. Over the treatment period, there were concerns in tissue. Thus, they have weak GABA mimetic features that raised regarding Mrs A about non-compliance and stockpiling the most likely drive the relaxation and experienced especially medication; hence she was started on depot medication. However, in the beginning of the drug therapy and during an overdose. There after three months, Miss A ceased engaging with the Community Care is a substantial tolerance against this euphoric high which is typical Coordinator and did not attend clinics for her ongoing regular depot 7 for addictive GABA mimetics like benzodiazepines or . injection. The major concern raised by Care Coordinator was that Miss Pregabalin is completely absorbed when taken orally with linear dose- A was stockpiling and misusing Pregabalin stating that it helps with 10 absorption relationship. It is eliminated via the kidneys with minimal her sleep. The Mrs. A gradually increased the dosage of Pregabalin by 10 and has no significant drug-drug interactions. The herself up to an alleged daily amount of 3000 mg. A multidisciplinary Pregabalin has a half-life of 5.5-6.7 hours, independent of dose and team meeting was held to discuss her care plan and manage her for 11 repeated dose administration. Findings from Australian studies are Pregabalin abuse. When Mrs. failed to collect prescription from consistent with researches indicating the serious and increasing harms Community Mental Health Team, she managed to collect these high 9,12,13 associated with Pregabalin worldwide. This built a rationale for doses of Pregabalin tablets either through a new General Practitioner regulation in and similar approaches being considered in

Submit Manuscript | http://medcraveonline.com Sleep Med Dis Int J. 2020;4(2):40‒42. 40 ©2020 Papanna et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and build upon your work non-commercially. Copyright: Pregabalin abuse as a sleep medication: case reports ©2020 Papanna et al. 41

or started buying it on streets from drug peddler. Mrs. A bought fact was that it was being misused. Multiple researches have shown Pregabalin online as well and started collecting at home. She used that Pregabalin discontinuation causes withdrawal symptoms similar to abuse Pregabalin along with other illicit . As per history to Benzodiazepine withdrawal with inability to sleep, excessive by Mrs. A, on a few occasions, she tried to discontinue Pregabalin anxiety, tremor and restlessness.18 There have been few incidents which resulted in very significant difficulty to with her sleep, high when Pregabalin dependent patients have taken overdose with the level of anxiety, extremely irritability and few times aggression and intention to die.14 We have come across number of patients under suicidal ideations.18 When Mrs A reported ongoing suicidal intent she our care in Community Mental Health Team, taking extra dose by was considered for inpatient admission which she agreed informally themselves as their need to go to sleep. On detailed history during and then needed to be detained under MHA.17 She needed very close clinics, Pregabalin is often bought by many patients illegally to use observation level 4 on the ward due to multiple suicide attempts by as and hypnotic. The first case Mrs. A described here showed ligature.19 Prior to admission she was using high doses of Pregabalin that Pregabalin abusers are often individuals with a history of poly and on ward she started re-experiencing Pregabalin discontinuation substance misuse. The high level of dosages reported with Mrs. A symptoms with major concerns with her sleep and anxiety levels.18 was in excess of daily maximum level (600mg daily) and clearly To treat the discontinuation symptoms she was started on were reason of concern. Online purchase of Pregabalin was another with appropriate dose titration. Her withdrawal symptoms were well significant concern, making it easy for service users to buy online managed with regular Diazepam 2mg BD along with up and misuse. Thus, changing its status as a controlled drug in United to 2mg daily as PRN medication. There was noticeable improvement Kingdom recently from 1 Aril 2019 has been a major step in preventing with sleep problem along with reduction of level of anxiety, suicidal its abuse. Pregabalin along with Gabapentin are now reclassified as thoughts and irritability. controlled drugs under Drug Misuse act 1971.10 However availability of Pregabalin with drug peddlers still remains a concern as it is with Case 2 any other illicit drug. Mrs B is a 54-year-old lady suffering from chronic fatigue syndrome In terms of management for Mrs A, it typically involved (Fibromyalgia) and back pain for many years. She has been under pain symptomatic treatment with long acting benzodiazepine to reduce management clinic and prescribed various pain medications including distress with withdrawal symptoms and gradually tapering the dose Gabapentin and Oromorph. She attended Community Mental Health over the period of time. This approach helped Miss A to come out Team with low mood, poor and increased anxiety about trivial things. of withdrawal symptoms. Mrs A required admission due to risk Her mood and anxiety were triggered by her ongoing physical pain. with suicidal ideations and need close monitoring. The randomized Mrs B was prescribed and to help with her controlled study by Arnold Lelsy et al.,16 reported that pregabalin mood and sleep but unfortunately both medications showed minimal improved pain in fibromyalgia patients with or without depressive benefit. Mrs B was involved physiotherapy and hydrotherapy for or anxiety symptoms.20 The pain relief property of Pregabalin can pain which helped her to some extent. Over the period Mrs struggled mediate the improvement in anxiety and depression due to reduced more with generalised anxiety and she was prescribed Pregabalin, pain which in turns improves sleep quality.20 This applied to Mrs B initially with 75mg BD and then increasing it to 150mg BD in few who reported improvement in her sleep following increasing dose of weeks’ time. Mrs B noticed significant improvement with sleep and Pregabalin. Another open label single arm study by Cho Yong Won anxiety and requested to increase Pregabalin dose to 300mg BD. & Mei Ling Song20 mentioned that Pregabalin is effective in the However, the medical team was reluctant to increase it as she was successful discontinuation of and it improves sleep quality already on a polypharmacy which might cause over sedation and in patients with .21 This explains effect experienced by Mrs B related complications. She was explained very well about the risks and her repeated demand for Pregabalin. It is interesting to note that in with increasing Pregabalin in addition to her current medication. both cases, Pregabalin was started for medical reasons. However due Mrs B had capacity to understand consequence and complications of to emergence of high tolerance and dependence, increasing dosages polypharmacy; however, she claimed that she was buying Pregabalin were eventually self-administered by patients themselves. The use of from the street as it is only medication which helps her with sleep. Pregabalin became a compulsion for them without which they could She found Pregabalin having very strong sedative and hypnotic effect not function well in their daily life. It was very clear that sudden for her. Mrs B appeared argumentative and very demanding to get it discontinuation of Pregabalin was associated with physical as well as although risk of over sedation, respiratory depression associated with psychological withdrawal symptoms, suggesting the high potential of Pregabalin particularly using more than prescribed dose especially Pregabalin to develop dependence. Benzodiazepines with long half- along with other sedative medications were explained to her. Mrs life were useful to manage withdrawal effects in both the patients. B mentioned that when she stopped Pregabalin or reduced dose for few days she started becoming unwell and had severe insomnia, flu Conclusion like symptoms with severe anxiety and increased irritability. It was very clear from Mrs B’s explanation that she developed dependence The conclusion we can draw from above two cases is that for Pregabalin and she was experiencing withdrawal symptoms Pregabalin has strong potential to develop dependence syndrome with on reducing the dose or stopping Pregabalin. Cross titration with symptoms which are mostly similar to Benzodiazepine dependence. benzodiazepine helped to manage withdrawal symptoms for Mrs B. Along with anti anxiety and analgesic properties, it has strong hypnotic properties as well and it contributes significantly towards Discussion development of dependence. Pregabalin is available on streets illegally and it is easily accessible for many patients to self-medicate In above case reports, patient Mrs A was abusing Pregabalin increasing risks to develop . In the treatment of Pregabalin particularly as hypnotic to induce sleep. There was a constant demand dependence, Benzodiazepines with longer half-life remain first line for Pregabalin with rationale that it helps with anxiety problem but the agents.

Citation: Papanna B, Lazzari C, Kulkarni K, et al. Pregabalin abuse as a sleep medication: case reports. Sleep Med Dis Int J. 2020;4(2):40‒42. DOI: 10.15406/smdij.2020.04.00071 Copyright: Pregabalin abuse as a sleep medication: case reports ©2020 Papanna et al. 42

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Citation: Papanna B, Lazzari C, Kulkarni K, et al. Pregabalin abuse as a sleep medication: case reports. Sleep Med Dis Int J. 2020;4(2):40‒42. DOI: 10.15406/smdij.2020.04.00071